by John B. Tebbetts, M.D.

At first, I couldn’t believe what I was seeing and hearing– in 2009, surgeon ads for “AWAKE BREAST AUGMENTATION” — and some of the ads from physicians who are not even plastic surgeons!  I thought I had seen every wrinkle of advertising in order to sell something old as something new,  resurrecting outmoded practices and techniques that failed to deliver optimal outcomes and recovery thirty years ago–and then trying to repackage and sell them to today’s prospective patients.  But seeing promotions for “awake augmentation”, I realize that marketing gimmicks never cease, and that uninformed patients may never know what can be if someone doesn’t tell them the truth about what is.

How do I know what is suboptimal with respect to the concepts and techniques of “awake” breast augmentation?  Because “awake” breast augmentation is how we did breast augmentations 30 years ago when I first started my practice.  It wasn’t optimal then, that’s why science has redefined what is possible for breast augmentation patients–and “awake” breast augmentation is not optimal for patients today.

“Awake” breast augmentation is not new or better.  Patients are not fully “awake”–the term “awake” can be misleading.  “Awake” patients are heavily sedated in order to allow a surgeon to perform augmentation with injected local anesthesia.  While some of the concepts of “awake” augmentation may sound appealing in marketing materials, ads, and commercials, let’s look at the facts–medically related facts first:

• Not a single, valid scientific study exists to prove that “awake” augmentation patients can recover as quickly, have as few complications, and have as few reoperations in the future as patients who have been treated with more advanced techniques and processe that use state of the art general anesthesia.  “Awake” augmentation is a marketing gimmick that promotes old practices and does not offer patients the most rapid recovery possible.
• “Awake”/sedated is not safer than asleep with optimal general anesthesia.  More about that later.
• The total amounts of anesthetic drugs administered to “awake” or sedated patients are much greater compared to the amounts administered with more state of the art anesthesia protocols, because the numbing effect of local anesthetic injected into tissues is painful on injection, and no amount of local anesthetic alone is adequate to allow a surgeon to perform an optimal breast augmentation.  More drugs means more side effects and a slower recovery–especially nausea, vomiting, and constipation.  More drugs means more potential for drug related complications.
• While being narcotized and sleepy after surgery may sound good compared to being out to dinner that night, it isn’t.  Scientific studies have conclusively shown that rapid recovery correlates directly with low complication rates and the lowest reoperation rates in the future.
• “Awake” patients cannot be afforded the protection of an endotracheal tube (a tube that seals the windpipe and protects against potential death from aspiration, a rare but dangerous aesthetic complication.  In fact, heavy sedation can actually increase risks of aspiration by impairing reflexes that guard against aspiration.  And when a surgeon tells you that endotracheal tubes cause a sore throat, know the facts.  With optimal anesthesia techniques, less than 10% of our patients experience a sore throat, and if they do, it’s gone in less than 8 hours.  End of the day, which is worse, a sore throat, or a potentially increased death risk from aspiration?
• “Awake” or sedated patients experience more bleeding and more trauma to their tissues during the operation, based on our 30 year clinical experience and published data.  More bleeding, even if stopped, means a greater risk of capsular contracture or hard breast that may require more reoperations.  More trauma to tissues also increases risks of capsular contracture, and dramatically increases the amount of pain a patient experiences after surgery.  A patient who can be up and out to dinner or shopping the evening of surgery has had much less bleeding and tissue trauma, or she couldn’t be up and out.  And rapid recovery patients have the lowest published rates of reoperations in the most respected scientific literature.
• “Awake” or sedated patients cannot receive optimal muscle relaxant medications during surgery.  No muscle relaxants means that the pectoralis muscle on the chest is much tighter, resulting in more trauma by instruments in order for the surgeon to expose the area of subpectoral pocket dissection.  More trauma, more pain, longer recovery, and more risk of capsular contracture from traumatized tissues.  A sedated, “awake” patient means that the surgeon has less optimal visualization and less optimal control of the details of the operation compared to an optimally anesthetized and relaxed patient.
• It is more difficult for anesthesia personnel to control blood pressure in a sedated patient compared to a patient with general anesthesia.  If the blood pressure rises, bleeding increases, the surgeon cannot see optimally, the operation is prolonged unnecessarily to stop the bleeding, and the risks of capsular contracture increase following augmentation.
• Every potential compromise and risk described previously for “awake” augmentation is substantially reduced or eliminated when surgeons use scientifically verified, peer reviewed and published techniques for state-of-the-art augmentation using optimal general anesthesia.

So much for the science and medical reasons why “awake” isn’t optimal for patients.  Now let’s consider the logic and legal considerations:

• It is illegal for any patient to make informed consent decisions while under the influence of drugs–especially when those drugs are sedatives and narcotics administered by her surgeon.  So where is the logic, and how legally defensible is it for an “awake” patient to make any decision or have any input about her operation while the operation is in progress?
• While it may sound appealing for a patient, friend, or significant other to provide input about breast size or other considerations during surgery, all decisions should be made by the patient and the surgeon prior to the operation, not while the patient is under the influence of drugs, and never by anyone other than the patient.
• Making good decisions is demanding before surgery for a fully awake and optimally educated patient.  No decision that a patient may make or input the patient may provide while under the influence of sedative and narcotic medications is optimal compared to a fully educated and fully awake patient.
• Educated patients rarely choose surgical alternatives that do not offer the most control for the surgeon, safety for the patient, and the least risk of complications, reoperations, or permanent tissue compromises or deformities.  “Awake” breast augmentation compromises optimal surgeon performance in many ways (read on).
• To avoid permanent and uncorrectable damage to patients’ tissues, decisions about breast or implant size should be based on precise tissue measurements that are different for each patient.  Those measurements and scientifically proved decision processes should than be used to plan breast and implant size before going to the operating room. History proves the high reoperation rates and uncorrectable tissue compromises and deformities that can result when patient or surgeon ignore tissue measurements and make decisions without optimal planning.  And history also proves the massive differences in patient recovery, outcomes, and reoperation rates when size decisions are made in the operating room based on visual opinions.

“Awake” breast augmentation prompts the question of who is asleep at the wheel—the surgeon, the patient, or both?  Why would a surgeon promote 30 year old practices that do not offer patients the best chance for the most rapid recovery and best outcome?  Why would a surgeon not want to learn, implement, and deliver what has been shown scientifically to be best for patients, instead of marketing what may be easier and require less knowledge of state-of-the-art processes?  And why would patients want to subject themselves to less than the best chance for an optimal recovery and the least risk of complications, reoperations, or uncorrectable deformites?   Why not make the effort to learn what is available, what is scientifically verified and state-of-the-art, and be out to dinner the evening of surgery with the least documented risks of problems in the future?

Just for the record, let’s put credibility and track record on the line for all to see–money where the mouth is.  I am more than ready and willing to compare the recovery and outcomes we deliver on a routine basis to any surgeon or surgeons’ results or data who promotes “Awake Breast Augmentation.”  Our outcomes and recovery is a matter of record in the most respected peer reviewed professional journal in plastic surgery.  And our patients’ recovery, results, and long-term reoperation rates are documented in those articles and in live surgery venues observed by hundreds of surgeons.  The scientific articles are HERE, and video documentation of our patient recovery is HERE.]

“Awake” breast augmentation is asleep at the wheel.

About the Author: John B. Tebbetts, M.D. is one of the world’s best breast augmentation surgeons, with a track record of innovations and scientific publications about breast augmentation that is unmatched by any surgeon worldwide. For more information about breast implants or Dr. Tebbetts, please visit www.thebestbreast.com.